Laserfiche WebLink
Waste Tire Su&y & Inspection ReporI Inspection Report: Number <br /> State of BCalifornia - <br /> rrn 8 Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board � <br /> Part A Surve BLUE OR BLACK INK PEN <br /> ax y� Tu�"M,�''�T4^�.;.' � � � r ry ?m ^ 7 ✓n Ir a'� i:' � "7r y F+w,' <br /> Inspection Type (Fill one) <br /> Site Suffix: �� <br /> _ ® Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 1 v1 �Lfi t lY t _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I — -- - <br /> —7� Inspected By Inspector <br /> Physical Address J — 1 - i <br /> ) . I i.A t <br /> L 3_ <br /> Street — <br /> !�'1 . Inspection Date }I t / / (.) / Q <br /> City State Zip Code Time In _ Time Out <br /> Business Rep Title Ell (]AM 11 AM_7_1 <br /> 0 PM 0 PM <br /> ifsr t <br /> Operational Status 5� Business Role �� totae�yrr `I <br /> r y (Fill one only) " � � I (Fill all that apply) NII" faltup ►y��� <br /> Tire Count(Whole/PTE) y, <br /> 4i twryc +� ur�yti <br /> Active is gift �F W u1 ti tMiu <br /> 0 Generator iuQ� wpu n <br /> �+ Latitude � . 0 Q Closed <br /> GPJ Q Hauler <br /> 'v <br /> inactive I�� �T� �"z" /t"'��+��w r <br /> Longitude <br /> — '��u �utiu 6rrsfr4 d �� nu a tit, <br /> g Q Planned tFraffl� �r Q End Use QF� t4�1 � <br /> rr ,.:'. r s�x �'r1di$� 31 rP. ✓^"ftp , <br /> " T <br /> iQ5lnGss Type (Fill all that apply) t a <br /> ` ,. �"_ <br /> UL <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government -Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Vj A HAULING AID MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments / <br /> (d ,1� �t. ;l�t:�•��(���t` GIC( ; <br /> M, "t��t<' �c � ✓�c:t�r�5. �+�r•'c ( v'� <br /> k 1 <br /> - — — <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> A „y 62081 <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X <br /> ■ �` <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />